The role of allied ophthalmic personnel in achieving universal eye health coverage in South Asia

The need for expansion of eye care services, primary eye care, early detection of blinding and potentially blinding conditions and injury is well-recognised. However, achieving these goals is not easy, given the limited availability of ophthalmologists. To tackle diseases and disorders that affect people’s vision, and to implement comprehensive eye care, sufficient availability of the eye care personnel at all levels is necessary.


VOLUME 33 • NUMBER 110 • 2020
Eye Health Community J ournal professionals have contributed to the expansion and growth of eye care services, besides playing a key role in the development of both specialised and primary eye care services in all the countries of the region.
In Nepal and Bhutan, a school graduate with ten years of schooling 2 and three years' training in ophthalmology, will perform the following tasks:  In Bangladesh, India, and Sri Lanka, most of these tasks are included in the training given to the AOPs. However, these AOPs are not allowed to work independently and prescribe drugs.
In Sri Lanka and Bangladesh, the training programmes for AOPs and optometrists are not recognised by government. Also, there is no accreditation nor any regulatory body for the purpose. In India, AOPs are trained on the basis of need. There is no uniform training curriculum or monitoring by any regulatory body. However, the country is in the process of considering these aspects under the proposed 'Allied and Healthcare Professions Bill, 2018'.
In the Maldives, where ophthalmologists and optometrists generally render the eye care services, there are no ophthalmic assistants or AOPs.
The Nepal Health Professional Council, set up by the government of Nepal, has issued the code of ethics and job description, to regulate the training programme for AOPs and their tasks across the country.
In Bhutan, the government recognises the importance of AOPs and is in the process of forming a regulatory body under the ministry of health.
With the effective utilisation of AOPs in Nepal, the productivity of ophthalmologists has gone up. Approximately 200 active ophthalmologists perform more than 300,000 cataract operations every year. The expansion of vision assessment and refraction services to all 77 districts of the country can be credited to AOPs.
Although AOPs have proven to play an important role in efficient eye care service delivery in most South Asian countries, some challenges still need to be addressed: • the absence of a proper body within the governments to ensure the quality of training, monitoring, and accreditation system for ongoing training programmes • absence of a uniform code of ethics, job descriptions and training curriculum • lack of defined career pathways for AOPs • absence of a professional body for human resources, at this level.
AOPs have always demonstrated their importance in eye care and can play a significant part in achieving the universal eye health coverage, as suggested by WHO. AOPs must be formally recognised, and their functions regulated in all the countries of South Asia. COMMUNITY  The Community Eye Health Journal is supported by:

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Figure 2
An ophthalmic assistant performs refraction, in Nepal Eye Hospital,

KATHMANDU NEPAL
YUDDHA SAPKOTA S ri Lanka is an island nation in the Indian Ocean, with a population of 21.5 million. It is identified as the fastest ageing nation in Southeast Asia. By the year 2050, one-third of the population in the country will be over 60 years of age. 1 The prevalence of blindness among people over 40 years of age in Sri Lanka is 1.7%, and that of low vision is 17%. Over 150,000 people are estimated to be blind, and a further 1.5 million are estimated to have low vision. 2 The ophthalmic services available are insufficient to address the eye care needs of Sri Lanka's population. The unavailability of local eye care services and the long distances people have to travel to seek eye care are significant barriers to access.
Ophthalmic nursing has become an important component of eye care globally, as it contributes towards the qualitative and quantitative improvement of the care provided. The roles and responsibilities of ophthalmic nurses vary from country to country. 3 In some countries, they are engaged in health promotion, prevention and intervention, while other countries have restricted their services.
The history of nursing in eye care in Sri Lanka starts in the early years of the last century, with the establishment of Colombo Eye Hospital in 1905. Most ophthalmic nurses in Sri Lanka work at eye hospitals and clinics.
There are three main eye health sectors in Sri Lanka where ophthalmic nursing is practiced: 1 Government and semi-government eye hospitals and eye units (Free-of-cost service) 2 Charity, partial charity, and not-for-profit eye hospitals 3 Private sector eye hospitals and departments.
However, there are no specific ophthalmic nurse training programmes within the ministry of health. Nurses in the first sector are trained at government general nursing schools operated by the ministry of health and at the government universities in Sri Lanka. 4 The diploma course takes two years, and the degree course takes three years. However, the nurses gain limited knowledge in eye care during their studies, as just two weeks are allocated to eye care.
Following graduation, nurses are posted to different hospitals. Those who are posted to eye units and eye hospitals receive hands-on training in addition to a few workshops conducted at their centres or at a central level. The type of training they receive, e.g., eye clinic practice, operating theatre procedures, or ward work, largely depends on their place of work. Structured continuing medical education programmes and postgraduate training in ophthalmic nursing are still not available in the country.
Nurses for the not-for-profit and private hospitals are trained in the nursing schools operating under the private sector. These institutions recruit nurses with a certificate in nursing, such as a diploma, and not a degree. They train them in-house, according to the requirements of the hospitals.
Ophthalmic nurses take on various roles, such as: • nursing manager or nursing sister • eye clinic nurse • operating theatre nurse • ward nurse • some nurses are given particular tasks, such as health education, infection control, community work, etc.
Colombo National Eye Hospital is the largest eye care centre in Sri Lanka, with over 400 beds. As a centre of excellence, the hospital caters to the whole country through different ophthalmic sub-specialities. Over 150 nurses are employed at this hospital, which has a very high volume of patients. There are over 50 smaller

Growing demand for nursing in eye care in Sri Lanka
Sri Lanka is in need of a policy framework and a firm action plan to increase the number of trained ophthalmic nurses.
A nurse attends to a patient at Lions Eye Hospital, Ratnapura SRILANKA

Figure 2
Nurses at Lions Eye Hospital in Colombo.

ASELA ABEYDEERA
ASELA ABEYDEERA eye units across the country, they are affiliated to government hospitals, and have fewer nurses assigned to them.
Ophthalmologists have noticed that the nurses have limited knowledge and training in anatomy, physiology and ophthalmic pharmacology. Therefore, the College of Ophthalmologists of Sri Lanka conducts periodic training and orientation programmes for them. The institutes for the nurses in Sri Lanka also conduct short refresher education programmes in clinical nursing. Despite these efforts, there is still a need for a structured postgraduate education in ophthalmic nursing in Sri Lanka.
There are five non-governmental charity hospitals for eye care in Sri Lanka (operated by Lions Club and HelpAge Sri Lanka), and dozens of private hospitals. All these institutions provide secondary and tertiary level eye care. Eye hospitals operated by Lions Clubs are involved in running occasional community eye care programmes, usually in remote areas. They use nurses as screeners and counsellors.
Overall, the available human resources in eye care are not sufficient to cater to the needs of the nation. In this context, the role of an ophthalmic nurse as a primary eye care worker is vital. As part of the VISION 2020 programme, during its early years, training and orientation programmes were conducted for public health midwives (PHM) in Sri Lanka. 5 Since PHMs are grass-root level health care workers, and are mainly involved in maternal and child health, they find it difficult to cope with the extra responsibilities assigned to them, including eye care.
The need for dedicated primary eye care workers/ nurses is well recognised. Successful primary eye care models need to be initiated to meet the growing need for eye care services in rural areas. Similar successful models are practised in other countries. For example, Aravind Eye Care System in India has proved the efficiency of utilising ophthalmic nurses at their vision centres. Rwanda showed encouraging results by engaging trained ophthalmic nurses in primary eye care. 6 During recent years, the ministry of health of Sri Lanka has started the exercise of assigning nurses to public health institutions, but without incorporating any specific eye care component.
The following measures are highly recommended for Sri Lanka, with regard to clinical and community-based ophthalmic nursing services, in order to achieve better eye care services, and make them accessible to all: • Advocate for policy regarding the importance of nursing in eye care and nurses' potential to improve eye care service delivery.
• Increase the number of nurses recruited in the government sector.
• Include primary eye care as an essential component in nursing curricula.
• Develop and deliver hands-on training in relevant areas in ophthalmology that the nurses can use in their jobs. This can be in-service training or continuing medical education-type learning processes.
• Recruit adequate number of trained ophthalmic nurses at primary health care institutions.
• Establish an effective referral system, initiated from the community eye nurse to the secondary and tertiary level eye care service providers.
• Follow up patients who need long-term care with the help of community eye nurses. Use a dedicated mechanism to do so. Bangladesh has sufficient general nurses trained, available, and are working in various Government health care facilities. Hence, the team decided to select and train general nurses as vision technicians to work at the vision centres. The selection criteria, although strict, was designed to maximise staff retention. Nurses had to: • live near the Upazila health complex • be willing to learn new skills and switch to a career in ophthalmology • be aged between 25 and 40 years.

Training
The nurses who were selected had to undergo two months of intense training at the National Institute for Ophthalmology in Bangladesh. This covered: • basic eye care • anatomy and functions of the eye • handling of basic ophthalmic equipment • visual acuity measurement • subjective refraction • identification of common eye conditions. After training the nurses were assessed for their knowledge and skills. This was followed by a 45-day intense training programme at Aravind Eye Hospital, the mentoring institute and its vision centres. This program provided hands-on training in the following areas:

Ophthalmic skills
These included visual acuity measurement, subjective refraction, retinoscopy, slit lamp examination, tonometry, identifying common eye conditions, fundus photography, ocular pharmacology, and treatment options for different eye conditions. CASE STUDY: BANGLADESH I n Bangladesh, eye care services are provided by the government, private hospitals, and local and international non-governmental organisations. However, access and coverage are still inadequate, as most ophthalmologists are located in urban areas, whereas 63 per cent of the country's population resides in rural areas. The current cataract surgical rate is 1,950 while the rate needed to address the backlog as well as new (incident) cases is estimated at 6,000. The Cataract Surgical Rate (CSR) is defined as the number of cataract operations done per million population per year.
Bangladesh requires a robust, scalable, and innovative solution to meet the need for cataract surgery and other eye services in the country. The health ministry therefore adopted a model developed by the Aravind Eye Care System. Under the model, trained ophthalmic personnel at the institute's telemedicine enabled vision centres (VCs) will offer eye care services at the primary level.

Government's role
The government decided to integrate primary eye care in the portfolio of primary health care services by setting up community vision centres. After making the necessary budgetary allocation, the government appointed a senior team consisting of the Director: National Institute of Ophthalmology, senior ophthalmologists, and heads of teaching hospitals in Bangladesh, to visit Aravind Eye Hospital in India. The team studied Aravind's Vision Centre model in detail and developed a strategic road map for implementing a similar model in Bangladesh.

The roadmap
The team decided to set up the first 20 community vision centres around a government tertiary eye hospital which would provide teleconsultation services, provide surgery, advanced investigations, and treatment to patients referred by the community vision centres. The team also decided that the community vision centers should be established in Upazila health complexes. Upazila refers to the third administrative level in Bangladesh and each of these covers a

Ophthalmic nurses in vision centres in Bangladesh
Bangladesh has adopted a structured approach to train general nurses as vision technicians, in order to address the shortage of trained eye care professionals in rural areas.

Information technology
This focused on the use of electronic medical records, and teleconsultation between patients and ophthalmologists at the base hospital.

Patient engagement
Counselling to enhance compliance with treatment.

Management
Managing supplies, equipment maintenance and generate reports.
The mentoring team at Aravind assessed nurses' new skills. On their return to Bangladesh, the newly qualified vision technicians then returned to the National Institute of Ophthalmology to continue learning and practising their skills until the first vision centres were launched.

Launch of community vision centres in Bangladesh
A team from Aravind Eye Hospitals, comprising the programme manager, vision technicians and an IT expert, worked closely with the team in Bangladesh, to set up the first 12 community vision centres. This helped to iron out first issues and ensured the smooth functioning of the community vision centres.
To build a cohesive working relationship between the vision technicians and the ophthalmologists at the tertiary hospital, both groups were invited to attend a workshop at the tertiary eye hospital, where the speakers emphasised the importance of the community vision centres and the vital role they play in extending effective eye care services to the rural population of Bangladesh.

Services delivered at community vision centre
• Carrying out comprehensive eye examination supported by teleconsultation with ophthalmologists.
• The Vision Technicians offer the services like dispensing spectacles and medicines as per e-prescription from ophthalmologists.
• Those requiring cataract surgery or advanced care are referred to the hospital.
Currently, there are 50 community vision centres in Bangladesh. Twenty are linked to a tertiary eye hospital (Sheikh Fazilatunnessa Mujib Eye Hospital and Training Institute), and 15 each are linked to two medical colleges (Rajshahi Medical College and Rangpur Medical College).

Sister Sathiraha
Bhodendranath is a general nurse who underwent intense training to become a vision technician at one of Bangladesh's 50 community vision centres.
"I was working as a staff nurse in Upazila health complex in Lohagara, Khulna when I applied to train as Vision Technician. I have always wanted to help people to regain their eyesight, so I was very motivated! The fact that vision technicians do not work night shifts was also very attractive.
The interviews were very competitive, so I was delighted to be one of the first group of 20 nurses selected to attend the initial training at the National Institute for Ophthalmology (NIO).
The shift from general nursing to ophthalmology was very challenging in the beginning. The two months of training at NIO boosted my confidence, and subsequent practical training at Aravind, with the continuous feedback they offered, really helped me to master the required skills.
I now see 20 to 25 patients per day, on my own; it is very satisfying work! The number of outpatients that come to us is increasing steadily, and the positive feedback from our patients is a motivating factor. The highlight of my career as a vision technician was when I demonstrated the vision centre model at the Digital Bangladesh Mela in 2020 with my colleague Mrs Smirti. We won an award at this Mela. I am working now as a vision technician in the community vision centre at Lohagara."

Base hospital
Months of operation (since)

Developing human resources
The core strategy of the initiative was to use locally available human resources to strengthen eye health services in the region. This was important because health professionals from outside the region were less likely to stay in those difficult conditions. The initial plan was to appoint qualified optometrists from outside the Sundarbans, but after analysing the ground realities, local young people were selected for training as Vision Technicians (VTs) and community health workers (CHWs).
The main challenge was the availability of suitable local candidates for the job. The local social organisations played an important role in identifying suitable candidates. The minimum eligibility for the position of VTs and CHW was high school class 12 and class 10, respectively. The total training period for VTs was one year; for CHWs, it was three months. A recognised training institute, a partner hospital, imparted this training.
The training covered awareness of common eye diseases and eye care workers' role in the management. It also covered counselling and outreach work. The trainers ensured that the VTs were well trained in retinoscopy for refraction. As a part of the project a baseline population based survey was conducted to assess the magnitude of blindness and visual impairment. All the newly trained VTs and CHWs participated in conducting the fieldwork. This helped them in understanding the ground realities of the service area.
Six months after the start of the program, more candidates has to be recruited and trained, as some candidates had left before completing their course.

CASE STUDY: SUNDARBANS
T he Sundarbans is a unique geographic area that is home to the world's largest mangrove forest and the Royal Bengal Tiger. Spread along the border between India and Bangladesh, the Indian section of the Sundarbans falls within the districts of North 24 Paraganas and South 24 Paraganas in West Bengal and consists of 106 islands; 52 of which are inhabited. Most islands are accessible by boat only, which makes life very challenging for the 4.7 million people who live in the Sundarbans. Nearly half of the population (47%) belong to the most marginalised groups in India: the Scheduled Casts and Scheduled Tribes. Over 40% of households live below the poverty line, and 13% come under the category of the 'poorest of the poor'. 2 Extreme levels of poverty and the challenging terrain limit access to health care and education. Many people are migrating to cities and towns for work due to shortage of job opportunities in the region. The insufficient number of health care providers is further adding to the woes of the Sundarbans.

Organising eye care in the Sundarbans
Any region with inherent geographical access barriers and socio-economic deprivation faces immense challenges in health care delivery. The Sundarbans is no exception in this context. However, the island network had an opportunity to improve this situation when Standard Chartered Bank came forward to support eye care services in the region. As a part of its 'Seeing is Believing' initiative, the bank supported the Sightsavers to implement, 'Sundarbans Eye Health Service Strengthening Project' in West Bengal. The objective of the five-year project, 2014-2018 , was to contribute to the elimination of avoidable blindness in the area. Sightsavers partnered with the government and three non-government organisations to implement the project.
Eye care for the people by the people: a case study from the Sundarbans Eye care service delivery in the Sundarbans of Bengal is an inspiring story in which concerted efforts involving training and participation of local resources led to a significant reduction of avoidable blindness.

Service activities
In total, 17 VTs were trained and then deployed to 17 vision centres in the region that had been established as part of the project. The VTs performed refraction and provided spectacles at an affordable cost. They also detected cataract and other conditions, and referred patients to hospitals run by the government or by non-governmental organisations. These centres provided spectacles to beneficiaries at an affordable cost. CHWs assisted the VTs in the mission.
An ophthalmologist from the base hospital visited the vision centres once in a month to attend to the referral patients and support the VTs and CHWs in various activities such as refining clinical skills, meeting local community etc. The VTs and CHWs also raised awareness of eye health by talking to people and offering one-to-one counseling and health education. Over some time, they came to be seen as a reliable source of information for the local community.
The hospitals organised eye screening camps in the remote villages inside the islands of Sundarbans, and held school eye examination near the vision centres with the help of VTs and CHWs. The CHWs distributed free spectacles to children who were identified through school screening and refracted at the vision centres. People who needed cataract operations were taken to the base hospital, in groups by hospital vehicles, and the follow-up was arranged at the vision centre. This entire service was offered free of cost to patients. 4

Training other health care workers
Training other groups of health care providers was a significant component of the project. The group included 1,467 Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) who operate at the grassroots level in the government health system. Also 2,380 Rural Medical Practitioners (RMPs) were included. RMPs are important health providers in remote areas. 3,585 health ambassadors, 70 paramedical ophthalmic staff, and 2,349 school teachers were given orientation programme in primary eye care. These personnel, in turn, worked closely with VTs and CHWs.

Assessing the impact -comparing baseline with the endline survey results
A population-based eye health survey was conducted in the Sundarbans in 2014, at the start of the project, to assess eye health status and health-seeking behaviour of the people in the region. The participants were individuals aged 40 years and above. As part of the survey, it was found that cataract and uncorrected refractive error were the leading causes of blindness and visual impairment. About 75.2 per cent of the sample had presbyopia, while less than half (46.2 per cent) had access to near vision spectacles. Of the remaining population, more than half (54 per cent) did not even realise that they needed spectacles. 5 These findings played an important role in strategic planning. The population-based survey was repeated in the same area, towards the end of the project in 2018, applying the same methodology. The key findings are summarised in table 1.
The results of the study indicate good progress in eye care in the Sundarbans, with improved coverage and quality of eye health services. Gender differences were not statistically significant. 6

Conclusion
For reaching out to the people residing in difficult geographical terrains, the local human resources are always the best choice to engage, in terms of their acceptance and effectiveness. Moreover, proper selection of candidates, good training and support can bring more success. The VTs are the face of the hospital or any programme in the community. The commitment levels of the VC staff and the quality of their services determine the success of the respective units. Retaining trained and efficient human resources continues to be a big challenge. The effective strategy lies in conducting continuous training for VTs to enhance their competencies and refining institutional policies in favour of retention. Periodic visits by senior staff from the base hospital can strengthen the relationship as well as improve the quality of service. The capacity building of local people indeed brings a sustainable change in health care. After the completion of the project the vision centres are being run by the local eye health workers under the management of respective partner hospitals.

Allied eye health professionals in eye care services in Nepal
Despite challenges, Nepal's eye care system is witnessing significant improvement, including an increase in eye hospitals and better cataract surgical coverage. From just one eye hospital in 1980, Nepal today has more than 40 secondary and tertiary hospitals, ophthalmic departments and more than 100 district and community eye care centres. The last three decades also witnessed significant progress in the development of the eye care workforce, making the country self-reliant in most of the human resources for its eye care services. 3 Allied eye health professionals have played a major role in these achievements.
The WHO Global Action Plan 2014-19 recognises a range of health care professionals as allied ophthalmic personnel. 4 Ophthalmic assistants/technicians, ophthalmic nurses, opticians, and ophthalmic photographer/imagers are the major allied health personnel in Nepal's eye care system. Nepal also has optometry technicians, orthoptists, vision therapists, ocularists and dedicated ophthalmic administrators, but in limited numbers.

Ophthalmic assistants
Ophthalmic assistants (OAs) form the backbone of the rural eye care structure in Nepal, where the services of ophthalmologists and optometrists are not sufficient to meet the need. Since 1981, over 1,000 OAs have been trained to assist ophthalmologists in outpatient departments, operating theatres and community outreach camps. 3 Their training included identification and management of common eye conditions and refractive errors. They also work as facility managers in the district and community eye centres. These are usually situated within the district headquarters, especially in the remote, mountainous regions. or community eye centres especially in remote, mountainous regions.

Opticians
It is estimated that about 350 formally trained opticians and an equal number of unregistered, informally trained dispensers are providing spectacle dispensing services in various outlets, mainly in urban areas and southern plains of the country.

Ophthalmic nurses
An estimated 120 ophthalmic nurses currently serve in eye hospitals and eye departments, assisting ophthalmologists in operating theatres and pre-and post-operative care. Ophthalmic nurse training is not available in Nepal, and the hospitals recruit general nurses, who gain in-service exposure to become ophthalmic nurses. 20 orthoptists (ophthalmic assistants trained for a year) work at different tertiary eye hospitals. With the availability of hospital management training in the country, the number of eye hospitals run by trained managers or administrators is gradually increasing.

Other allied eye care personnel
In addition to these personnel, 'eye workers' provide supporting roles at hospitals and eye care centres across the country. The training for these workers is not standardised, and are based on the needs of the eye hospitals.

Challenges
• Equitable distribution of the workforce is one of the major challenges faced by the allied eye care personnel. For example, the Karnali province, the least developed regions in Nepal has 17 OAs (1 OA per 90,000 people) compared to 210 (1 OA per 30,000 people) in Bagmati pprovince. A similar pattern is likely for opticians and other allied eye care personnel.
• There are concerns about the retention of these professionals. Of the 1,025 registered OAs, only 625 are estimated to be active in the eye care sector. Factors such as poor job satisfaction, low salary and other incentives, lack of career growth, and an inappropriate match between the skills they have and those that the job demands may be responsible for demotivation and high attrition.
• Insufficient government involvement in eye care services has also led to fear about job security among all levels of the ophthalmic workforce.
• Training programmes for several of these personnel are not available in the country, and the programmes (e.g., optician and orthoptists) that are available are sporadic and lack standardisation.

Opportunities
Despite these challenges, several opportunities exist to maximise the contribution of the allied ophthalmic personnel to eye care in the rural areas of Nepal. The National Ophthalmic Health Policy 2017 envisages integration of primary eye care into the existing primary health system, although this has not yet been implemented. The changing trend in eye diseases presents further opportunities for these personnel in primary eye care. Whereas cataract and refractive errors are major causes of vision impairment, the rising burden of diabetic retinopathy, glaucoma and other age-related eye diseases demands mobilisation of allied health personnel in awareness creation, early detection and primary prevention activities in an integrated health system. It is also encouraging to note that new training opportunities are being standardised for opticians.

Conclusion
Allied ophthalmic personnel in Nepal have made a significant contribution to eye care services. However, their reach to the rural areas beyond district headquarters, is limited due to lack of integration into the existing primary health care system. Government job opportunities, standardised training, career opportunities, and incentives can help address the inequitable distribution and concentration of these personnel in urban regions. Further investigation is required to understand the effectiveness and impact of these professionals, as well as the factors associated with their recruitment and retention within the country's eye care sector. The role of allied ophthalmic personnel becomes crucial when there is a shortage of ophthalmologists. A well-trained person can enhance the efficiency, productivity and quality of eye care teams. Without them, eye programmes would suffer from low productivity, increased costs, and a lack of consistency in the delivery of quality eye care.
In this article, we consider ways to maximise the contribution of allied ophthalmic personnel.

Training should be relevant
When designing a training curriculum, it is important to consider the tasks allied ophthalmic personnel may be expected to carry out (whether in the community or in a clinic) and to teach the specific competencies they require. It is equally important to focus on the aspect of attitude, alongside the skills and knowledge being imparted to trainees.
We strongly advise carrying out a competency-based assessment at the end of training to ensure that trainees are ready to take up their role in the eye health workforce.

Standard operating procedures
It is crucial to draft standard operating procedures (SOPs) to minimise inconsitencies in the eye care. The SOPs, or work instructions, provide a great deal of clarity and guidance to allied ophthalmic personnel, allowing them to work effectively and safely to provide high quality care. They also help in delivering a higher quality of care. SOPs must be drafted with the involvement of AOPs, as it ensures that the the details of each task are also standardised. Though some of these are classified as general tasks, some have to be linked explicitly with the institution.

Part of a team
Allied ophthalmic personnel must be deployed according to need, and their skills should align with the duties they are expected to perform. The skill set of AOPs should align with the duties they are expected to perform. AOPs often work as part of a team; hence, their roles should be clearly defined within the context of their teams. At eye clinics that carry out comprehensive eye examinations, shifting the responsibility for carrying out routine tasks to allied ophthalmic personnel will help ophthalmologists work more efficiently, allowing them to be deployed more effectively. Proper execution of 'task-shifting' depends on the competency levels of the opthalmic personnel.

Ocular emergency management
Allied ophthalmic personnel should be trained to efficiently provide the first-level care for ocular emergencies, such as foreign bodies, lid lacerations, corneal injuries and chemical injuries. At the primary levels of care, where ophthalmologists are usually not available in sufficient numbers, the role of these personnel becomes vital. They should be taught when and where to refer patients that require further intervention. (See table 1

Higher-order skills
Allied ophthalmic personnel can also be trained and deployed to perform more specialised tasks, such as dispensing low vision aids, rehabilitation, counselling caregivers of paediatric patients, and making ocular prosthesis. These functions offer new opportunities for career advancement. Training has to be intensive with sufficient practice under supervision, until candidates are certified as competent and qualified. Experienced personnel can also be deployed to supervise and train their team members.

Equipment and instruments
It is essential to empower allied ophthalmic personnel with the instruments needed to carry out their functions well. These instruments should be in good working condition. According to WHO statistics, in developing countries and rural areas, more than 50% of the ophthalmic instruments and equipment are not functional. Dysfunctional equipment severely affects the performance of ophthalmic teams. In order to provide quality eye care services, it is essential to maintain equipment in the proper condition. With the right training, allied ophthalmic personnel can be effective in the day-to-day care and maintenance of equipment and instruments, including being able to fix common problems.

Leveraging technology
Several new technologies are now available to help allied ophthalmic personnel to perform their tasks faster and with better accuracy. Eye institutions should familiarise themselves with new developments and invest in technologies, as required. For instance, a lensometer helps opticians determine the refractive power of a lens, faster than manual lens neutralisation methods. New technologies and mobile applications also improve speed and quality, significantly reducing training time. For example, personnel can use mobile applications such as Peek Acuity in screening. With health information management systems, mobile applications offer cheaper and portable alternatives that may be easier to use.
Today, technology can perform specific tasks that were traditionally performed by trained eye health personnel. For example, autorefractors have been shown to measure refractive errors as effectively as someone who is trained in performing refraction. These tools are simple to operate, with basic instructions, and do not require extensive training. They also play a vital role when there is a shortage of human resources for eye health.
The advent of telemedicine has brought significant gains, as it is now easier to deploy the allied personnel in remote and rural areas. Telemedicine has helped to establish an interface between patients, allied ophthalmic personnel, and ophthalmologists; thereby enhancing access to eye care. In recent years, telemedicine has also been augmented with digital imaging and artificial intelligence. Technology not only enhances the scope of services allied ophthalmic personnel can offer at the primary level, but also increases the productivity of ophthalmologists at the tertiary level.
Allied ophthalmic personnel are essential members of any eye team. It is imperative to provide them with appropriate training and clarity about their role so they can deliver high-quality eye care effectively. With the proper deployment, supported by technology, these personnel can be highly productive. In the process, it is also important to systematically identify the factors that reduce their effectiveness, and address them through continuous improvement and innovation.  Table 1 shows different tasks and skills that could be performed by ophthalmic personnel.
T here is a need for more skilled and competent allied ophthalmic personnel (AOP) to deliver comprehensive eye health services in India. 1,2 Mission Saksham is an initiative that aims to improve eye care delivery and reduce poverty by offering free AOP training to young men and women from economically vulnerable communities.

Scholarship program
Mission Saksham is supported by the Wen Giving foundation with the aim to train more allied ophthalmic personnel in India by offering scholarships to people from economically vulnerable and marginalised communities. The first phase aspires to train 2,000 candidates by 2025.
The broad objectives of Mission Saksham are to: 1 Strengthen the capacity of allied ophthalmic personnel in the country: • As of January 2021, a total of 236 (female: 160 and male: 44) students were enrolled in various ophthalmic courses at four tertiary eye care institutions in India. Periodic monitoring of the ongoing course by project staff, parameters like the attendance of the students and grades scored are used a proxy indicators of quality. Phase -II of this initiative involves collaborating with three new partner eye care institutions, to train about an additional 250 AOPs.
2 Standardising the teaching curriculum and training programs: • In the absence of a central/national accreditation body in India, it is hoped that every hospital will adopt its curriculum, examination patterns and teaching modalities. Under Mission Saksham, we looked at 35 different AOP courses across the country and found that about 80 % do not have accreditation. Efforts are underway to encourage these hospitals to obtain local accreditation for the courses.
• Mission Saksham invests in building the capacities of partner eye care institutions in the country, including standardising of their AOP training programmes. Consequently, Mission Saksham identified a total of 14 partner eye care institutions, and efforts are underway to build their capacities by conducting regular workshops. Efforts are ongoing, in partnership with several leading eye care centres in the country, to build institutional capacity through the development of standardised curriculum, course material, course design, and faculty training.
3 Empowering youth from challenging backgrounds -especially those from smaller towns and rural background.
• The potential AOP candidates to be trained are selected from economically weaker backgrounds. The identification and selection of candidates is made in partnership with the local partner eye hospital; candidates whose monthly family/household income is less than or equal to Rs. 10,000 (roughly US $135), are given priority. About 70% of place is reserved for women candidates. Scholarships are provided to the selected candidates, to cover tuition fees, monthly stipend, free boarding and food facilities, and supplies including uniforms, books and stationery.

Initial impact and way forward
The first group of 11 AOPs completed the training in 2019 and was placed in a partner hospital. Hailing from modest backgrounds, these trained AOPs now earn between Rs. 7,000 and 10,000 (the US $96 -137) every month, contributing additional income to their households. Also the 29 students who have graduated in the 2019-2020 , have served a total of 24,600 patients in those years combined.
In future, mission for vision will identify, partner, and network with new eye care institutions, to train AOP candidates in the country.

Training allied ophthalmic personnel to meet India's eye care needs
A new initiative aims to train young people from disadvantaged backgrounds in India as allied health personnel. T he role of allied ophthalmic personnel in the effective delivery of eye care has been highlighted repeatedly. 1,2 This underscores the importance of nationallevel commitment, that recognises the levels and initiatives for effective training. 3 Little has been done towards advancing these personnel and training them appropriately.

References
Creating growth and advancement opportunities is essential to make eye care an attractive career option, and to retain trained staff members. This article explores various ways in which organisations can structure the career growth opportunities for their allied ophthalmic personnel while making the most of their potential.

Why must organisations create growth opportunities for AOPs?
It is important to offer opportunities for career development, not just to retain talented people, but also to ensure that they have opportunities to function to their fullest potential. Offering staff members a structured career path is attractive and can significally reduce the cost of recruitment and re-training. Also, the annual performance appraisals for AOPs help evaluate their performances and offer career development opportunities. These factors motivate their peers to give their best at work and help reinforce good performances. i

Different paths
Promoting the staff to positions of higher responsibilities would mean change in designations, along with added supervisory responsibilities.
• Promoting to more specialised areas: For instance, an AOP who typically attends to patients with cataract or refractive errors may be trained and promoted to assist in taking care of the patients with retinal disease or children with amblyopia.
• Offering opportunities to become trainers, coaches or mentors: This is relevant to the teaching institutions, where the teaching resources are precious and take time to build.
• Offering partial or full support to pursue higher education within their career track: This essentially helps in building a workforce with a high calibre combined with valuable experience. However, this may be affected by the availability of limited formal training programmes for AOPs in the region.

Harness Innovation
In addition to formal promotions and career pathways, opportunities can also be created by enhancing the enthusiasm of AOPs. These AOPs are generally efficient at their work and are keen to improve regularly. Providing opportunities for innovation and learning is an ideal way to keep them engaged better, while also harnessing innovation. Given the nature of their work, the AOP staff are at the forefront of eye care and face many ground-level problems. Often, such situations also have good ideas in store. Organisations must provide opportunities for the staff to participate more actively by coming up with ideas and suggestions, allowing experimentation and tolerating failures. When combined with good improvement science, the passion of these professionals can lead to the generation of great ideas and solutions to everyday problems.

Paving the career path for allied ophthalmic personnel
To build a formidable pool of trained allied ophthalmic personnel, retention, combined with the provision of opportunities, is vital.

Case Study
Aravind Eye Hospital offers career advancement positions to AOPs who have more than three years of work experience. Those who are exceptionally good at their work are recognised as 'performers'. These staff members are also eligible for promotion as 'supervisors' (who take up leadership and supervisory roles) or as 'tutors' (who take up the role of senior trainers). The eligible candidates are assessed to see if they are fit to take up these positionsdue diligence is carried out to ensure that they are suitable for the positions of higher levels of responsibilities. For instance, a 360-degree feedback is carried out to ensure that a staff member is eligible to become a supervisor. The selected candidates then receive additional training and orientation to fit into these new positions.
Also, the AOPs are provided support to pursue university programmes, such as a diploma in Ophthalmic Assisting, so that they can acquire formal recognition relevant to their work.

RAJKUMAR/ ARAVIND EYE CARE SYSTEM
Continues overleaf ➤

Launch entrepreneurs
The organisations empower AOP staff with entrepreneur opportunities in the field. The eye hospitals encourage trained AOP staff to run vision centres in remote and rural areas, creating a win-win situation. By providing this opportunity, the hospitals can optimise resources that would be spent in reaching out to these communities. Often, these AOP staffs hail from these regions and have a better chance of acceptance and inclusion into these regions. If appropriately empowered, these entrepreneurs can continuously improve patient volumes, uptake of surgery and glasses, and ensure compliance to treatment.

Academic opportunities
The AOPs can also identify new growth opportunities by becoming trainers and extending academic advancement. The training institutions can offer teaching roles to AOPs for internal and external training. The academic opportunities range from giving opportunities to participate in research, to encouraging presentations and participation in conferences, or may involve support to pursue higher education. The hospitals can also encourage AOPs towards participating as either learners or teachers in continuing professional education programmes.

Make sure the transition is smooth
It is crucial to prepare the trainee for a new position in the right manner. Organisations often make the mistake of promoting candidates without preparing them for the new responsibilities. It is vital to ensure that proper training and orientation are given to the staff to help them succeed in their new roles. They may need to acquire new competencies, such as leadership skills. A clear job description of the new role helps in setting expectations for them. A certain amount of hand-holding during this transition period is also essential. All these must be included in the organisation's career advancement programme for AOPs.

Points to note
Opportunities in career development alone cannot guarantee retention, as there are several contributing factors. 4 While planning these opportunities for the AOP staff, it is equally important to consider internal and external contexts. Meticulous planning and due diligence must be applied in choosing the right candidates for advancement. A formal performance appraisal, combined with career development, can be a great incentive and motivation for eye care workers. 5 atlas.iapb.org/vision-trends/eye-health-systems/ (last accessed 09 Sep 2020). G lobally, 253 million people are estimated to be visually impaired, of whom 36 million are blind. In the recent past, significant changes were made to the definitions of visual impairment and blindness, which has ensured that vision loss due to uncorrected refractive error is not excluded when estimating the burden of visual impairment.
The World Health Organisation has adopted the International Classification of Diseases 11 (ICD 11) definition of visual impairment and blindness. According to this definition, a person is said to be visually impaired if the presenting VA in the better eye is worse than 3/60. In this revised definition, near vision impairment is also included; it is defined as presenting near VA worse than N6 with existing correction.
Decision-makers in government use definitions of blindness and vision impairment when formulating policies to provide financial support and other benefits for those certified to be legally blind. For instance, in India, people who are legally blind can avail free public transportation and the assistance of scribe during examinations, etc.
The definition of blindness under India's National Programme for Control of Blindness (NPCB) is different from the current definition adopted by the World Health Organization in the International Classification of Diseases -10 (ICD-10). The VA criteria under which an individual will be classified as blind in the two definitions are different, being 20/200 in the NPCB definition, and 20/400 in the ICD-10 definition after the 2006 revision. In India, the Ministry of Social Justice and Empowerment (MoSJE) is responsible for developing programmes that extend support to people with disabilities. As a recent initiative, the ministry has recommended that the revision of the blindness be cut off to 20/400 instead of 20/200 that is currently followed by NPCB. The only difference is the MoSJE classification will be applied to any person based on the best-corrected VA, and not the presenting VA. It is essential that the same criteria be used universally under all the programs associated with policymaking and service provision for the blind and the visually impaired.
Another important definition pertains to functional low vision. This is defined as 'VA less than 6/18 up to the perception of light, with treatment and best possible refractive correction, or visual field less than 10 degrees from the point of fixation'. This is an important definition for the sake of the evaluation, because a person with this vision may benefit from low-vision devices and services. Such a person must be encouraged and trained to maximise the potential benefit from the residual vision, often with the help of assistive devices and specific lifestyle changes.
It is important to note that the VA alone does not determine the overall quality of vision required for optimal functioning. The functional assessment of the vision comprises the visual field, colour vision, stereopsis, extraocular motility, contrast sensitivity, glare sensitivity and night vision, besides VA. All these are considered for specific critical licensing procedures, such as the issue of driver's and pilot licences, and determining eligibility for civil services, etc.
Driving is a complex activity where the driver should consider multiple objects in the visual field, scan the moving objects with precision to exercise sound judgment, and recognise coloured signals. Thus, aspects such as visual field, colour vision and contrast sensitivity are considered necessary while issuing a driving licence in certain countries. In India, the issue of a driving license for light motor vehicles is based on self-assessment and issue of a medical certificate , that cover the following vision-related aspects: • In case of presence of any refractive error, whether it has been corrected with suitable spectacles • Visual acuity: The ability to read a vehicle's number plate from a distance of 25 metres, translates to a VA of 6/12, as the standard size of these characters is 65mm • Colour vision: the ability to distinguish the pigmentary colours -red and green • Whether a person suffers from night blindness.

Understanding definitions of visual impairment and functional vision
The legal definition of blindness assumes great importance in extending device-related support to those suffering from visionrelated problems. Whereas Visual Acuity (VA) alone does not determine the quality of vision, certain other factors too have to be considered, specifically for the issue of driving licenses.

DEFINITIONS Continued
In India, driving license is issued by Regional Transport Offices (RTO) in every state, and the procedure is regulated by the Motor Vehicle Act (MVA) 1988, amended in 2017.
For an unrestricted (non-commercial) driving licence, it is recommended that, with both eyes, the applicant should have a VA of 6/12 or better, and an uninterrupted visual field of 120° or better in the horizontal meridian. There are lacunae in the mandatory standards for issuing driving licences, that needs to be addressed.
According to the International College of Ophthalmologists' (ICO) visual standards for driving, regular testing of contrast sensitivity and glare sensitivity has to be done. The licences should be renewed after a definite period, and people above 65 years of age should be evaluated more frequently. The licences can be issued with restrictions if the need arises. For a commercial driving license, a VA of 6/9 in the better eye, and 140° horizontal field of vision is required. If the uncorrected VA is < 6/24, the application for the licence is rejected.
Monocular or one-eyed persons are eligible for the driver's license, if the VA in the remaining eye is 6/12 or better, the horizontal visual field is 120 degrees or more, and at least six months should have passed after the loss of vision in the eye, for monocular adaptation.
Extrapolating the results of a clinical examination and aiding in rehabilitation can be complemented by the functional assessment of vision. The functional vision assessment includes a variety of evaluations to understand the impact of visual impairment in the daily activities of life and guide them to make successful adaptations.

Visual acuity
It is the spatial resolving capacity of the visual system and measures the sharpness of vision. Visual acuity is usually measured using a Snellen's chart at a distance of 6 meters or 20 feet. Several other charts are available for specialised conditions. Normal vision is denoted as a visual acuity of 6/6 or 20/20. Near VA measures the ability of a person to see objects at a working distance -usually about 40 cm or 16 inches.

Visual fields
A visual field refers to the entire area that can be seen by the eye when fixated at a point. It is measured by a confrontation test, tangent screen, Humphrey's field analyser or Goldman perimetry. It is significant to note that the presence of normal visual fields enables orientation mobility and helps while searching. In the case of glaucoma, retinitis pigmentosa, and many other neurological conditions, there is a possibility of the presence of a defect in the visual fields. This can be in the form of central scotomas and peripheral constrictions. An Amsler's grid can be used to measure the central fields, as it is essential in ascertaining legal blindness.

Colour vision
It is important to be able to distinguish colours well. The colour vision is assessed using D-15 panel test, and Ishihara pseudoisochromatic coloured plates. As part of rehabilitation, patients can be advised to seek high colour and tone contrast. The Ministry of Road Transport and Highways (MoRTH) amended Form 1 and Form 1A of the Central Motor Vehicles (CMV) Rules, 1989, to enable the citizens with mild to medium colour blindness, obtain the driving licence. However, restrictions on severe colour blind citizens in case of driving, still apply.

Contrast sensitivity
Contrast sensitivity is a measure of the ability to discern different levels of luminance in a static image. It can be measured using Lea's contrast test or Pelli Robson chart. Loss of contrast sensitivity caused by other ocular conditions will also affect the VA. People with low vision typically face difficulties in viewing objects or prints that have low contrast. Such persons are advised to adopt settings that offer good contrast, so that seeing becomes more comfortable, for example, rice in a dark bowl.

Glare sensitivity
It is a measure of how quickly drivers can resume control of their vehicles when suddenly blinded by the lights of a vehicle approaching in the opposite direction. The glare is the result of excessive brightness within the visual field, due to various factors, such as cataract, corneal scarring, albinism, and retinal dystrophies. The glare can significantly reduce the VA. Brightness acuity tester (BAT) can be used to ascertain the visual disability caused due to glare. It can also be assessed by the reduction in visual acuity, following prolonged exposure to a light source.

State of binocularity and stereopsis
The Worth's Four Dot Test, is used to diagnose the sensorial relationship between the two eyes. Red-green goggles dissociate the images seen by the two eyes. The testing is done at 20 feet and 13 inches, with the Worth-four-dot flashlight for macular fusion placed at a distance, and the peripheral fusion positioned in the proximity. This is a common adaptation to strabismus, amblyopia, and aniseikonia.
Stereopsis refers to the perception of depth or the relative proximity of an object. Determining the exact relationship of vehicles, animals and pedestrians, in the driving environment, is the most challenging aspect of the visual factors. It should be kept in mind that stereo acuity is not equivalent to depth perception, but is one of the many visual cues meant for determining the depth. This is tested using TNO and random-dot stereograms.

Night vision
Defective night vision is seen in patients with retinal disorders, such as retinitis pigmentosa, and those with cataracts. It is also seen in people with intraocular lenses or those who underwent a refractive operation when a wide pupil exposed the edges of the IOL or of the ablation zone. The latter group of patients may also experience glare and loss of contrast sensitivity.
It is important for eye health workers to understand the functional assessment of vision, as it directly translates into visual efficiency in daily activities. This will not only aid in the development and interpretation of policies but also help in designing an enabling an ideal environment for children with visual impairment or any other disabilities. Assessment of central fields using Bjerrum screen. INDIA